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psnet.ahrq.gov/node/34726/psn-pdf
April 19, 2011 - How house officers cope with their mistakes.
April 19, 2011
Wu AW, Folkman S, McPhee SJ, et al. How house officers cope with their mistakes. West J Med.
1993;159(5):565-569.
https://psnet.ahrq.gov/issue/how-house-officers-cope-their-mistakes
In this article, the authors report on how house officers cope with their…
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psnet.ahrq.gov/node/35704/psn-pdf
March 28, 2011 - Relationship between patient complaints and surgical
complications.
March 28, 2011
Murff HJ, France DJ, Blackford J, et al. Relationship between patient complaints and surgical
complications. Qual Saf Health Care. 2006;15(1):13-6.
https://psnet.ahrq.gov/issue/relationship-between-patient-complaints-and-surgical-co…
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psnet.ahrq.gov/node/47925/psn-pdf
August 21, 2019 - Second victims and mindfulness: a systematic review.
August 21, 2019
S Miller C, Scott SD, Beck M. Second victims and mindfulness: a systematic review. J Patient Saf Risk
Manag. 2019;24(3):108-117. doi:10.1177/2516043519838176.
https://psnet.ahrq.gov/issue/second-victims-and-mindfulness-systematic-review
The secon…
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psnet.ahrq.gov/node/41498/psn-pdf
December 31, 2014 - Standard practices for computerized clinical decision
support in community hospitals: a national survey.
December 31, 2014
Ash JS, McCormack JL, Sittig DF, et al. Standard practices for computerized clinical decision support in
community hospitals: a national survey. J Am Med Inform Assoc. 2012;19(6):980-7. doi:10.…
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psnet.ahrq.gov/node/43529/psn-pdf
October 01, 2014 - National pediatric anesthesia safety quality improvement
program in the United States.
October 1, 2014
Kurth D, Tyler D, Heitmiller ES, et al. National pediatric anesthesia safety quality improvement program in
the United States. Anesth Analg. 2014;119(1):112-21. doi:10.1213/ANE.0000000000000040.
https://psnet.ahr…
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psnet.ahrq.gov/node/60968/psn-pdf
September 30, 2020 - Assisting beginners in root cause analysis operations:
analysis and recommendations regarding the spread of
COVID-19 in nursing facilities for the elderly.
September 30, 2020
Tsuchiya H. Assisting beginners in root cause analysis operations: analysis and recommendations
regarding the spread of COVID-19 in nursing …
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psnet.ahrq.gov/node/847735/psn-pdf
May 30, 2023 - SOPS Ambulatory Surgery Center Survey: What You Need
to Know.
May 30, 2023
Agency for Healthcare Policy and Research: April 27, 2023.
https://psnet.ahrq.gov/issue/sops-ambulatory-surgery-center-survey-what-you-need-know
Ambulatory surgery centers (ASC) experience a variety of error types that can be exacerbated by…
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psnet.ahrq.gov/node/39450/psn-pdf
February 17, 2011 - Malpractice reform—opportunities for leadership by
health care institutions and liability insurers.
February 17, 2011
Mello MM, Gallagher TH. Malpractice reform--opportunities for leadership by health care institutions and
liability insurers. N Engl J Med. 2010;362(15):1353-6. doi:10.1056/NEJMp1001603.
https://psn…
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psnet.ahrq.gov/node/42774/psn-pdf
May 28, 2015 - Patient safety in plastic surgery: identifying areas for
quality improvement efforts.
May 28, 2015
Hernandez-Boussard T, McDonald KM, Rhoads KF, et al. Patient safety in plastic surgery: identifying areas
for quality improvement efforts. Ann Plast Surg. 2015;74(5):597-602.
doi:10.1097/SAP.0b013e318297791e.
https:…
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psnet.ahrq.gov/node/858324/psn-pdf
December 13, 2023 - Many people of color worry good health care is tied to
their appearance.
December 13, 2023
DeGuzman C. KFF Health News. December 5, 2023
https://psnet.ahrq.gov/issue/many-people-color-worry-good-health-care-tied-their-appearance
Racial and ethnic bias permeates medical interactions to detract from safe and effecti…
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psnet.ahrq.gov/node/46592/psn-pdf
December 19, 2017 - The evolution of procedural competency in internal
medicine training.
December 19, 2017
Sacks CA, Alba GA, Miloslavsky EM. The Evolution of Procedural Competency in Internal Medicine
Training. JAMA Intern Med. 2017;177(12):1713-1714. doi:10.1001/jamainternmed.2017.5014.
https://psnet.ahrq.gov/issue/evolution-proce…
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psnet.ahrq.gov/node/43826/psn-pdf
June 01, 2015 - Radiation Oncology Incident Learning System.
June 1, 2015
American Society for Radiation Oncology and American Association of Physicists in Medicine.
https://psnet.ahrq.gov/issue/radiation-oncology-incident-learning-system
Reporting of near misses and adverse events can provide a foundation for learning from error.…
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psnet.ahrq.gov/node/44270/psn-pdf
July 01, 2015 - Improving Patient Safety Culture Through Teamwork and
Communication: TeamSTEPPS.
July 1, 2015
Chicago, IL: Health Research & Educational Trust; June 2015.
https://psnet.ahrq.gov/issue/improving-patient-safety-culture-through-teamwork-and-communication-
teamstepps
This guide draws from the experience of organizati…
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psnet.ahrq.gov/node/38636/psn-pdf
May 20, 2009 - Impact of the Accreditation Council for Graduate Medical
Education work-hour regulations on neurosurgical
resident education and productivity.
May 20, 2009
Jagannathan J, Vates E, Pouratian N, et al. Impact of the Accreditation Council for Graduate Medical
Education work-hour regulations on neurosurgical resident …
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psnet.ahrq.gov/node/73238/psn-pdf
May 12, 2021 - Medical Residents and Burnout
May 12, 2021
Coverdale J, West CP, Roberts LW, eds. Acad Med. 2021;96(5):611-769;e14-e21.
https://psnet.ahrq.gov/issue/medical-residents-and-burnout
Medical training is a demanding experience that impacts a learner’s ability to provide safe care, cope, and
remain healthy. This is…
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psnet.ahrq.gov/node/44073/psn-pdf
April 15, 2015 - Clinician support: five years of lessons learned.
April 15, 2015
Hirschinger LE, Scott SD, Hahn-Cover K. Patient Saf Qual Heathc. April 2015;12:26-31.
https://psnet.ahrq.gov/issue/clinician-support-five-years-lessons-learned
This magazine article relates insights from an academic health care system that developed a…
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psnet.ahrq.gov/node/72827/psn-pdf
March 10, 2021 - Coronavirus Commission for Safety and Quality in
Nursing Homes.
March 10, 2021
Centers for Medicare and Medicaid Services. McLean, VA: MITRE Corporation; September
2020.
https://psnet.ahrq.gov/issue/coronavirus-commission-safety-and-quality-nursing-homes
Nursing homes have been confronted with numerous …
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psnet.ahrq.gov/node/47513/psn-pdf
October 24, 2021 - Measurement and Monitoring of Safety Framework
October 24, 2021
Healthcare Excellence Canada.
https://psnet.ahrq.gov/issue/measurement-and-monitoring-safety-canada-cpsi-safety-improvement-project
Collaboratives are a recognized strategy to support large-scale improvement. This program works to apply
a framework fo…
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psnet.ahrq.gov/node/48049/psn-pdf
May 29, 2019 - How one health system overcame resistance to a surgical
checklist.
May 29, 2019
Hilton K, Anderson A. Harv Bus Rev. May 20, 2019.
https://psnet.ahrq.gov/issue/how-one-health-system-overcame-resistance-surgical-checklist
This commentary describes how one health system worked to combat resistance to change associate…
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psnet.ahrq.gov/node/47342/psn-pdf
August 22, 2018 - The doctor doesn't listen to her. But the media is starting
to.
August 22, 2018
Fetters A. The Atlantic. August 10, 2018.
https://psnet.ahrq.gov/issue/doctor-doesnt-listen-her-media-starting
Women face implicit bias that can affect the safety and effectiveness of their care. Reviewing several high-
profile accoun…